Provider Demographics
NPI:1942227756
Name:MINOR, RANDAL EUGENE (CERTIFIED OCULARIST)
Entity Type:Individual
Prefix:MR
First Name:RANDAL
Middle Name:EUGENE
Last Name:MINOR
Suffix:
Gender:M
Credentials:CERTIFIED OCULARIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17817 GUNN HWY
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-1967
Mailing Address - Country:US
Mailing Address - Phone:813-949-2500
Mailing Address - Fax:813-345-8488
Practice Address - Street 1:17817 GUNN HWY
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-1967
Practice Address - Country:US
Practice Address - Phone:813-949-2500
Practice Address - Fax:813-345-8488
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5416100001Medicare NSC